ATI RN
ATI RN Custom Exams Set 2
1. The client diagnosed with diabetes mellitus type 2 is admitted to the hospital with cellulitis of the right foot secondary to an insect bite. Which intervention should the nurse implement first?
- A. Administer intravenous antibiotics
- B. Apply warm moist packs every two hours
- C. Elevate the right foot on two pillows
- D. Teach the client about skin and foot care
Correct answer: A
Rationale: Administering intravenous antibiotics is the priority intervention in this scenario. Cellulitis is a bacterial skin infection that requires prompt treatment with antibiotics to prevent its spread and potential complications. While warm moist packs and elevation can be beneficial as adjunct measures, they are not the initial priority. Teaching about skin and foot care is important, but it can be addressed after stabilizing the acute condition with antibiotics.
2. A nurse is instructing a group of clients regarding calcium-rich foods. Which of the following foods should the nurse include in the teaching as the best source of calcium?
- A. 1⁄2 cup ice cream
- B. 1 ounce Swiss cheese
- C. 1 cup milk
- D. 1 cup cottage cheese
Correct answer: 1 cup cottage cheese
Rationale: Cottage cheese is the best source of calcium among the options provided. It is rich in calcium and provides a significant amount per serving. 1 cup of cottage cheese contains more calcium compared to 1⁄2 cup of ice cream, 1 ounce of Swiss cheese, or 1 cup of milk. Ice cream is not a significant source of calcium and is often high in sugar and fat. Swiss cheese and milk contain calcium, but cottage cheese has a higher calcium content per serving, making it the best choice for meeting calcium needs.
3. A nurse is reviewing the health history of a client who has a hip fracture. What risk factor should the nurse identify for developing pressure injuries?
- A. Frequent repositioning
- B. Poor nutrition
- C. Increased fluid intake
- D. Use of a special mattress
Correct answer: B
Rationale: Corrected Rationale: Poor nutrition increases the risk of developing pressure injuries as it impairs skin integrity and healing. Frequent repositioning, increased fluid intake, and the use of a special mattress are all important interventions for preventing pressure injuries, rather than risk factors for developing them. Repositioning helps relieve pressure, adequate fluid intake maintains skin hydration, and special mattresses redistribute pressure to prevent injuries.
4. A client with end-stage cancer receiving Morphine is prescribed Methylnaltrexone. The client's daughter asks why the provider prescribed Methylnaltrexone. Which of the following responses should the nurse make?
- A. The medication will increase your mother's respirations.
- B. The medication will prevent dependence on the Morphine.
- C. The medication will relieve your mother's constipation.
- D. The medication works with the Morphine to increase pain relief.
Correct answer: C
Rationale: The correct response is C: 'The medication will relieve your mother's constipation.' Methylnaltrexone is an opioid antagonist used to treat severe constipation unrelieved by laxatives in opioid-dependent clients. It works by blocking the mu opioid receptors in the GI tract, which helps alleviate constipation without affecting pain relief or causing withdrawal symptoms. Choices A, B, and D are incorrect. Methylnaltrexone's primary action is related to managing constipation rather than increasing respirations, preventing dependence on Morphine, or enhancing pain relief when used alongside Morphine.
5. A nurse is caring for a client who is 2 hours postoperative following a cholecystectomy. Which of the following actions should the nurse take to prevent postoperative complications?
- A. Instruct the client to perform deep breathing and coughing exercises.
- B. Have the client wear sequential compression devices (SCDs).
- C. Place the client in a supine position with the head of the bed flat.
- D. Encourage the client to ambulate every 2 hours.
Correct answer: B
Rationale: The correct answer is B: Have the client wear sequential compression devices (SCDs). Following a cholecystectomy, the client is at risk for venous thromboembolism (VTE) due to reduced mobility and surgical stress. SCDs help prevent VTE by promoting venous return and reducing the risk of blood clots. Choices A, C, and D are incorrect. While deep breathing and coughing exercises are essential postoperatively, SCDs take precedence in preventing VTE. Placing the client in a supine position with the head of the bed flat can increase the risk of respiratory complications. Encouraging ambulation is important, but SCDs are a higher priority in this situation to prevent VTE.